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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 7. EMPLOYMENT BENEFITS |
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Chapter 7-1. [DELETED] |
Section 7-127. MODIFYING, SUSPENDING OR TERMINATING BENEFITS
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127.1The Program may make an ED to modify, suspend, or terminate a claimant’s benefits.
127.2 A claimant who is receiving benefits under the Program shall not be the subject of an ED unless and until there is sufficient evidence to support the issuance of an ED pursuant to the Act and this section.
127.3 An ED may be based, in whole or in part, upon the following factors:
(a) The award of compensation was for a specific period of time which has expired;
(b) The death of the claimant;
(c) Clear evidence that the claimant has returned to work;
(d)Clear evidence that the claimant has been released to return to work;
(e) The claimant has been released to or has returned to work on a part-time or modified duty basis, notwithstanding that the claimant has been directed to undergo vocational rehabilitation under section 2304 of the Act;
(f) The claimant has been convicted of fraud in connection with the claim;
(g) The claimant’s failure to participate in vocational rehabilitation, failure to cooperate with the Program's request for a physical examination by a treating or AME physician, or failure to follow prescribed and recommended courses of medical treatment;
(h)The claimant’s failure to cooperate with the subrogation process pursuant to § 143 of this chapter;
(i) Controversion of the claim for two (2) years pursuant to § 112.7;
(j) Retirement of the claimant;
(k)Clear evidence that the claimant has knowingly and willfully received benefits to which he or she was not entitled under the Act;
(l)The cessation or lessening of a compensable injury;
(m) The condition is no longer causally related to the claimant’s employment with the District government;
(n) The condition has changed from a total disability to a partial disability;
(o) The Program has offered the claimant a modified duty position and the claimant has refused to accept the position, pursuant to § 137 of this chapter;
(p) The Program determines based upon strong compelling evidence that the ID was in error; or
(q) Any other ground demonstrating that the Act requires the claimant’s benefits to be modified.
127.4 With the exception of the factors set forth in paragraphs 127.3(a) through (k) and § 127.5, compensation benefits subject to an ED shall not be modified or terminated until the period for requesting reconsideration set forth in § 128 has elapsed with no Request for Reconsideration being received by the ORM, or until a timely Request for Reconsideration has been decided by the ORM, whichever is earlier.
127.5The Program may modify or terminate compensation benefits subject to an ED simultaneous with notice to the claimant, pursuant to §§ 127.3 and 127.4, when:
(a) A claimant’s treating physician has released a claimant to return to work; or
(b) An AME physician has released a claimant to return to work and the claimant’s treating physician has either agreed with the AME physician’s opinion or has not disagreed with the AME physician’s opinion.
127.6If the claimant’s treating physician disagrees with the AME physician’s opinion, then the Program shall not modify or terminate the claimant’s benefits until the period for requesting reconsideration set forth in § 128 has elapsed with no Request for Reconsideration being received by the ORM, or until a timely Request for Reconsideration has been decided by the ORM, whichever is earlier.
127.7In making its determinations regarding whether a claim should be the subject of an ED, the Program shall consider all relevant evidence in the claim file, including all relevant medical evidence.
127.8Medical reports that fail to meet the requirements of § 123.13 may be deemed to be invalid and compensation claims based thereon may be denied.
127.9The ED is effective unless the claimant succeeds on a Request for Reconsideration under § 128 of this chapter or prevails at a hearing under § 129 of this chapter, or the Program revises the ED.